When Emergency Contraception (EC) Was Introduced

When the FDA approved the use of Emergency Contraception (EC), and Planned Parenthood began to make it available, my supervisor and I met to define my changing role.  It was only available by prescription then, so I had no direct role in distributing it, but my role in providing education—timely education—could potentially be significant in preventing unwanted pregnancies. Many people had never heard of it yet, or if they had, many had misinformation, so I needed to be thorough in my approach.

When it first became available, EC could be taken up to 72 hours after unprotected sex.  (It later changed to 120 hours, or 5 days).  I was to explain how it worked, preventing pregnancy after unprotected sex, and that if someone was already pregnant when they swallowed EC they would still be pregnant; it would not end, or terminate, an existing pregnancy.  It is completely different from a medical abortion, but many people were unaware of the differences.

Prior to EC, if anyone came to me concerned that they might be pregnant, my job was to stress the importance of getting a pregnancy test as soon as appropriate, keeping in mind that it usually takes 2 weeks for a pregnancy to show up on a urine test, but that the sooner the better after those first 2 weeks.  So for several years, my timeframe assessment had been straightforward.

Now it was going to change.

Now, if someone approached me concerned that they might be pregnant, I had more to assess than simply when to schedule an appointment for a pregnancy test.  I needed to pause there and get the timeframe: if they had had unprotected sex within 72 hours, they might be a candidate for the new EC.  I could provide general information about it, assess interest, and if they were interested I was to contact the clinic to try to get them in immediately.  The receptionists and nurses were similarly trained to put “Walk-in EC” as a top priority.

So according to my new flow chart, if someone expressed concern over a potential pregnancy, if unprotected sex had happened within 3 days (72 hours) I was to follow the EC line of questioning. If it had been between 3 and 14 days ago, I was to offer to help them schedule a pregnancy test as soon as possible after day 14, and if it had already been more than 14 days, I was to encourage a pregnancy test right away, and offer to schedule it.

Armed with my newly memorized flow chart, during the first weekly teen drop-in after my EC training, I was faced with my first potential EC patients; 2 teen girls came to my office saying, “We think we’re pregnant.”

“Do you wantto be pregnant?” I asked.

“No!” they replied in unison.

“Have you heard about the new EC pills?” I asked.

“Huh?” one of them replied.

“If someone has had unprotected sex and they don’t want to become pregnant, there are new pills called Emergency Contraception, or EC, that can be swallowed up to 72 hours after unprotected sex, to try to prevent pregnancy.  Do you mind if I ask, did either of you have unprotected sex within the last 72 hours, or 3 days?” 

Thinking I was prepared with my flow chart for any answer they might provide, one of them simply looked down at the floor and replied, “Not to the best of my knowledge.”

“Could we have lunch with you fifth period?”

I was in an office in the high school with Peggy, my new colleague, training her.  I didn’t know the girl who spoke, or either of her two friends in my doorway.

“Sure!” I replied.  I was glad that Peggy would get to “shadow” a visit with a new group.  When they showed up for lunch, they had two more friends with them.

“Could they stay, too?” the leader asked.

“Sure,” I replied.  They were delightful girls, eager to talk, jabbering away as they munched on their pepperoni rolls, unfazed by the fact that my tiny office could barely fit us all.  They quickly identified that they knew to come to us because of the program we had done the previous week; they said it had been really helpful.

“I’m glad you found it helpful,” I said, and added, “So, do you agree with what we said; that most teens who get pregnant didn’t want to?  That it’s by mistake?”

“Definitely!  More like all than most!”

“And do you think most teens think about that?” I asked.

“Like, since that program, I been thinking about it a lot,” one girl said.

“Me, too!” chimed in her friend.

They went on to tell us stories, often with several of them talking at the same time.  Two of them had never had sex and were determined to wait.  Two others thought they might be pregnant, including one who admitted she had had unprotected sex for weeks including as recently as the weekend.  I was glad they were all willing to talk so openly with us and with each other, despite their varied experiences.  We talked about everything from how to involve their parents to how to get birth control to correct condom use and pregnancy tests.  It was a lively and productive visit and they all wanted to meet again next week.  Each one took a parental permission form and promised to get it signed, so we could continue to meet in school.  When the bell rang and they left, I was glad we didn’t have a student scheduled the next period; that visit had provided an important glimpse into how teen girls’ minds work, how they communicate, and how we can help them.  I wanted some time alone with Peggy to make sure she was learning what she needed to learn.

“Wow, that was pretty intense; I’m glad you got to see it,” I said to Peggy.

She was exhausted just from watching.  Exasperated, she said, “I can’t believe it!  I mean: did you hear those girls?”  She was outraged.  “I mean, weren’t they listening to us last week?  They said they were there, they said they liked it, but I mean—what the hell?!  One of them admitted she had unprotected sex this past weekend: that’s after our program!  I mean—we might as well have not even been there!  How do you do this?  I mean, we told them everything, but she still had unprotected sex!  What’s the point?!”

“Well, yes, she admitted she has been having unprotected sex, and she admitted she did it this weekend, that’s true.  But think about it.  I mean, she’s been having unprotected sex for several weeks; that’s what she said.”

“I know.  I can sort of see it if she hadn’t thought about it before.  But last weekend?!  That means our program did nothing!”

“Well now, wait a minute.  It’s true that she didn’t just go from having unprotected sex to protecting herself immediately after our forty-three minute program.  But to me, what’s significant about that visit is not the fact that a teenage girl who attended our program had unprotected sex anyway.  What’s significant to me is the fact that she’s been having unprotected sex repeatedly and after our program she now has adults she can turn to for guidance in changing the direction: she clearly stated that she wants to graduate without getting pregnant first, and that she’ll keep meeting with me to make a plan to go on a method.  She’s only in ninth grade: it’s just luck that she hasn’t turned up pregnant already, but who knows how long that luck will last.  No, what I see as significant is the fact that in high schools all across this country there are girls just like these, many of whom are having sex.  But this group has someone to talk to about it.  The fact is that we helped start her on a road in a different direction.”

It took a little more prodding, but within a few minutes Peggy did see that just because there wasn’t immediate behavior change on the riskiest girls’ behavior didn’t mean we had failed.  It meant we had started a valuable process that I’d continue and that we had hopefully reached her at a pivotal time, before it’s too late.

“Oh yeah, it’s Friday: Vivian day.  I’m so glad you’re here!”

I was relieved to get such an enthusiastic greeting from Valerie King when we arrived at the same time in the high school parking lot.  She was a special education teacher who had been with the district for twenty years.

Secretly, I had wanted to hide when I saw her: she and I had both recently learned that one of the girls in her class was pregnant.  She had referred the girl to me three years prior, and she knew I had been meeting with her frequently.

“I’m glad to hear you say that, and I’ll admit it, a bit surprised.”  Playfully, I added, “I thought you’d wanna send me packin’!  I know this is a tough year for you with Shelby pregnant.”

“Oh, goodness, are you kidding?  That is so nothing.  I mean, hell, she’s a senior!  She made it a lot farther than any of us thought.  And anyway, the school year is almost over, and she’s the only one!  I mean yeah, she’s a tough one, but hey, it’s not like it used to be here.  It used to be like I’d have five or six every year!  One year we had eleven; you’re making such a difference!”

I thanked her for the support but was also careful not to accept the compliment as mine alone; without the network of people sharing a vision and a commitment to it, I couldn’t have done anything alone.  But working together, we had made a big difference in our community.

I remember when Eileen, my boss, confirmed both how effective and unique our model was: having me serve as a support to individual teens and as a bridge to medical services.  A few years after we started the project, my Planned Parenthood affiliate, like many in the nation, merged with another local affiliate, doubling our territory overnight.  So Eileen suddenly had to oversee education services in four counties.  She immediately hit the ground running, setting up meetings with key people in the two “new” counties, building relationships with professionals in health, human services, and education in this vast new area.

Several months after the merge, she told me, “Vivian, you have to realize something.  You’ve spent more time with teenagers—alone and in small groups—listening to them talk about sexuality in a non-clinical setting than anyone in four counties.  So any time you’re talking with anyone in our four counties, you need to realize: you’ve got more direct experience listening to teens than anyone.”

She also said why she was telling me that: she wanted me to realize that in my day to day interactions with other professionals in related fields, I should always trust my experience first.  If someone told me something about teen sexuality that didn’t sit right with me, I should be confident in my gut reaction, because it probably comes from a more realistic perspective.  And I should not be hesitant to “call people” on things I hear in the community about teens; how they think, how they behave, what they need: there are a lot of misconceptions out there, and I should use my voice to correct them.

“That’s impossible!” I insisted.  “And anyway, you can’t possibly know that yet.  Yeah, you’ve met a lot of people, but even within our four counties, you don’t know everyone.”

“I know I don’t.  But I don’t need to.  I’ve looked at the computer; I’ve studied the numbers.  If there was anyone else who was talking with teens the way you are, and having the impact you’re having, we’d see it in the numbers.  We’re Planned Parenthood: the vast majority of teens who access reproductive health services come to us.  We’d see a little blip in the numbers; some zip codes would have a disproportionate number of teens initiating and continuing services.  And we’re not seeing that.  We always see a certain percentage of teens; it doesn’t vary that much.  But the work you’re doing in Springfield, we see a disproportionate number of teen patients, both initiating coming in for services and following up.  You need to realize nobody else is doing work like that in our four counties…”

Wow.  Although it was affirming to learn that my work was having a measurable impact, it was chilling to hear that nobody else in four counties was doing similar work, having a similar impact.  I still considered myself “new” at this; I had been with Planned Parenthood for less than five years; with something as important as preventing teen pregnancy, I didn’t want to believe that our society didn’t have a lot of people with more training and experience than I had.

But the sad truth was that she was right.

And the sadder truth is that that’s true for most of our nation.